Long-term health-related quality of life of breast cancer survivors remains impaired compared to the age-matched general population especially in young women Results from the prospective controlled BREX exercise study

AbstractObjectiveTo investigate long-term health-related quality of life (HRQoL) changes over time in younger compared to older disease-free breast cancer survivors who participated in a prospective randomized exercise trial.MethodsSurvivors (aged 35–68 years) were randomized to a 12-month exercise trial after adjuvant treatment and followed up for ten years. HRQoL was assessed with the generic 15D instrument during follow-up and the younger (baseline age ≤ 50) and older (age >50) survivors’ HRQoL was compared to that of the age-matched general female population (n = 892). The analysis included 342 survivors.ResultsThe decline of HRQoL compared to the population was steeper and recovery slower in the younger survivors (p for interaction ConclusionsHRQoL developed differently in younger and older survivors both regarding the most affected dimensions of HRQoL and the timing of the changes during follow-up. HRQoL of both age groups remained below the population level even ten years after treatment.</p

A graphical LASSO analysis of global quality of life, sub scales of the EORTC QLQ-C30 instrument and depression in early breast cancer

We aimed to (a) investigate the interplay between depression, symptoms and level of functioning, and (b) understand the paths through which they influence health related quality of life (QOL) during the first year of rehabilitation period of early breast cancer. A network analysis method was used. The population consisted of 487 women aged 35-68 years, who had recently completed adjuvant chemotherapy or started endocrine therapy for early breast cancer. At baseline and at the first year from randomization QOL, symptomatology and functioning by the EORTC QLQ-C30 and BR-23 questionnaires, and depression by the Finnish version of Beck's 13-item depression scale, were collected. The multivariate interplay between the related scales was analysed via regularized partial correlation networks (graphical LASSO). The median global quality of life (gQoL) at baseline was 69.9 +/- 19.0 (16.7-100) and improved to 74.9 +/- 19.0 (0-100) after 1 year. Scales related to mental health (emotional functioning, cognitive functioning, depression, insomnia, body image, future perspective) were clustered together at both time points. Fatigue was mediated through a different route, having the strongest connection with physical functioning and no direct connection with depression. Multiple paths existed connecting symptoms and functioning types with gQoL. Factors with the strongest connections to gQoL included: social functioning, depression and fatigue at baseline; emotional functioning and fatigue at month 12. Overall, the most important nodes were depression, gQoL and fatigue. The graphical LASSO network analysis revealed that scales related to fatigue and emotional health had the strongest associations to the EORTC QLQ-C30 gQoL score. When we plan interventions for patients with impaired QOL it is important to consider both psychological support and interventions that improve fatigue and physical function like exercise.Peer reviewe

A graphical LASSO analysis of global quality of life, sub scales of the EORTC QLQ-C30 instrument and depression in early breast cancer

We aimed to (a) investigate the interplay between depression, symptoms and level of functioning, and (b) understand the paths through which they influence health related quality of life (QOL) during the first year of rehabilitation period of early breast cancer. A network analysis method was used. The population consisted of 487 women aged 35-68 years, who had recently completed adjuvant chemotherapy or started endocrine therapy for early breast cancer. At baseline and at the first year from randomization QOL, symptomatology and functioning by the EORTC QLQ-C30 and BR-23 questionnaires, and depression by the Finnish version of Beck's 13-item depression scale, were collected. The multivariate interplay between the related scales was analysed via regularized partial correlation networks (graphical LASSO). The median global quality of life (gQoL) at baseline was 69.9 +/- 19.0 (16.7-100) and improved to 74.9 +/- 19.0 (0-100) after 1 year. Scales related to mental health (emotional functioning, cognitive functioning, depression, insomnia, body image, future perspective) were clustered together at both time points. Fatigue was mediated through a different route, having the strongest connection with physical functioning and no direct connection with depression. Multiple paths existed connecting symptoms and functioning types with gQoL. Factors with the strongest connections to gQoL included: social functioning, depression and fatigue at baseline; emotional functioning and fatigue at month 12. Overall, the most important nodes were depression, gQoL and fatigue. The graphical LASSO network analysis revealed that scales related to fatigue and emotional health had the strongest associations to the EORTC QLQ-C30 gQoL score. When we plan interventions for patients with impaired QOL it is important to consider both psychological support and interventions that improve fatigue and physical function like exercise

Patient-Reported Outcomes in Older Breast Cancer Survivors With and Without Prior Chemotherapy Treatment

BACKGROUND: Little is known about long-term treatment-related symptoms in older breast cancer survivors. We characterized long-term patient-reported symptoms and examined factors associated with the presence and severity of symptoms, and symptom interference with daily activities. METHODS: Texas Cancer Registry (TCR) Medicare linkage data was used to identify breast cancer patients age 65 and older with local/regional stage disease diagnosed between 2012-2013. Symptom burden was assessed using breast-specific items from the Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE™). Demographic and clinical data also were collected. Logistic regression models were used to assess the association between symptom burden and respondent sociodemographic and clinical characteristics. RESULTS: Of 4448 eligible patients, 1594 (response-rate 35.8%) completed questionnaires. Of these, 1245 eligible respondents were included in the analysis based on self-reported data. Median time from diagnosis to survey completion was 68 months (IQR: 62-73). Most frequently reported symptoms were fatigue/lack of energy (76.8%), aching muscles (72.1%) and aching joints (72.5%). Receipt of chemotherapy was associated with higher symptom burden. Patients treated with adjuvant chemotherapy had higher risk of numbness/tingling (OR: 3.16; 95% CI: 2.36-4.24), hair loss (OR: 2.72; 95% CI: 2.05-3.60), and fatigue/lack of energy (OR: 1.80; 95% CI: 1.29-2.52). Similarly, patients who received chemotherapy were more likely to report the majority of symptoms as moderate to severe and as interfering with daily activities. CONCLUSION: Receipt of chemotherapy is associated with significant symptom burden more than 5 years after breast cancer treatment. Long-term chemotherapy impact should be discussed with patients in a shared-decision making process and approaches to symptom management during survivorship care are needed

Investigating Physical, Social, Emotional, and Health Frailties of Cancer Survivors after Cancer Treatment: The Urgent Call for Tailored Multidisciplinary Survivorship Plans in Italy

Background: Understanding the specific needs of cancer survivors is essential for healthcare policy. In Italy, dedicated studies are lacking, so we aimed to investigate the physical, mental, social, and health difficulties encountered by these patients. Methods: We conducted a cross-sectional study on breast or colorectal cancer survivors (people 5+ years free from it and its treatments) using an ad hoc survey including validated questionnaires (Grauer&ndash;Palombi, SF-36, PREDIMED). Participants were recruited within the Oncology Unit of the &ldquo;Policlinico Tor Vergata&rdquo;, Italy. Results: A total of 62 patients (80.6% females; years range: 37&ndash;87) agreed to be interviewed. A profile of cancer survivors was drafted: an overaged person with multiple co-morbidities, not well-nourished, adhering to the Mediterranean diet, reporting critical conditions as for physical and functional status. The mean number of co-morbidities was 3.6 &plusmn; 2.4 SD, with a statistically significant difference between age groups (under and over 65). Compared to the general population, the sample showed more frailties, especially when &gt;65. The risk of having multimorbidity (four or more co-morbidities) significantly increased in those over 65 (OR: 4.72; CI: 1.43&ndash;15.59). Conclusion: There is an urgent need for survivorship care planning for the patient-centered continuum of care. Assessing and monitoring their specific needs will help propose appropriate and tailored responses

Health-related Quality of Life of Patients Treated With Different Fractionation Schedules for Early Prostate Cancer Compared to the Age-standardized General Male Population

Peer reviewe

Surgical Treatment of Breast Cancer and Patient Reported Outcomes : Special Emphasis on Health-Related Quality of Life and the Cost of Care

Breast cancer patients’ health-related quality of life (HRQoL) is an important quality indicator in breast cancer care. HRQoL is recommended to be studied with both generic and disease-specific HRQoL measuring tools. Different techniques in breast cancer surgery affect the patients’ well-being in different ways. Patient-dependent factors and tumour biology both have their impact on treatment choices. Knowledge of breast cancer patients’ HRQoL in relation to different surgical methods is still scarce. The method and timing of breast reconstruction is under debate between immediate breast reconstruction (IBR) and delayed breast reconstruction (DR). Pressure on societies caused by the rising incidence of breast cancer is associated with a need for health-economic evaluations to guide resource allocation on cancer treatment. This thesis evaluates breast cancer patients’ HRQoL in different states of the disease and compares different measuring tools to detect differences between them and produce data on their validity. Different surgical methods to treat breast cancer are studied in relation to HRQoL. All available breast reconstruction methods and the timing of reconstruction are evaluated. The cost of care from the care providers’ perspective is also described during a two-year prospective follow-up. This thesis produces new information concerning HRQoL measuring tools and their usability in breast cancer; how breast cancer treatments performed in Finland affect the patients’ HRQoL and how the costs of different surgical methods are generated. This thesis is based on two study populations. 840 breast cancer patients treated in the Helsinki and Uusimaa Hospital district from 2009 to 2011 were recruited to a cross-sectional observation study as part of a study of prostate, colorectal, and breast cancer patients. Patients filled in an informed consent form and three different HRQoL measuring tools: EQ5D-3L (including VAS), 15D and EORTC QLQ C-30 BR23. Their answers were analysed with linear, stepwise regression analyses. Individual study population of 1065 patients with primary breast cancer were recruited to a prospective study from year 2008 to 2015 in Helsinki and Uusimaa Hospital District. Recruited patients filled in an informed consent form and two HRQoL questionnaires: the generic 15D and breast-cancer specific EORTC QLQ C-30 BR23. The questionnaires were handed out at the first hospital visit and repeated via mail at 3, 6, 12 and 24 months later. Clinical data were collected from hospital records, combined with HRQoL results and then analysed with statistical methods. Data on cost of care were obtained from the ECOMED database, analysed and presented according to the surgical method. EQ5D was associated with a high ceiling effect with 41% of the patients reporting perfect health; other measuring tools performed with less ceiling. Breast cancer patients’ HRQoL deteriorated along the disease progression with patients reporting fatigue, pain and sleeping disorder symptoms. The prospective follow-up included 351 mastectomies, 415 breast resections, 248 oncoplastic resections and 51 immediate breast reconstructions (IBR). 402 patients went through axillary clearance. 840 patients (79% of all) received radiation therapy and 523 (49%) chemotherapy, 766 (72%) patients had endocrine treatment, and 119 (11%) patients had targeted therapy (anti HER2- medication). 41 patients had later corrective surgery and 34 patients had DR. HRQoL was affected by disease status and by the disease burden. Higher Grade, N-class and BMI (body-mass index) correlated with poorer HRQoL at 3 months. The effect of N- and M-class and receiving chemotherapy still correlated with poorer HRQoL at 24 months. Active smoking correlated with complications. Mastectomy patients had the poorest HRQoL throughout the study period and they reported the most pain and arm symptoms. Patients operated on with oncoplastic techniques had the best body image at 24 months. Reconstruction patients had the best physical and sexual functioning scores at 24 months. Reconstruction patients’ recovery after treatments was the slowest. No difference was found between different autologous reconstruction methods. The lowest costs from surgery were observed in BCS patients (mean 6015 euros). Mastectomy was associated with mean costs of 8114 euros, IBR with 18 217 euros, and DR with 19 041 euros. EQ5D-3L is associated with high ceiling effects. Consequently, care must be taken when choosing HRQoL measuring tools. Breast cancer patients frequently reported insomnia, pain and fatigue, indicating the main focus on symptom handling. Mastectomy patients are at risk of poor HRQoL and higher symptom burden. Oncoplastic techniques produce good HRQoL and body image. Breast reconstruction produces good HRQoL, physical - and sexual-functioning scores, but the improvement in HRQoL materialises later than in BCS patients. Breast reconstruction method and timing should be tailored individually, and no patient should be pushed toward reconstruction before being ready for it. The cost difference between IBR and DR is relatively small, so the cost of reconstructive surgery should not be a factor in the decision making.Elämänlaadun arvioiminen on noussut erittäin merkittäväksi tekijäksi arvioitaessa rintasyöpähoitojen vaikuttavuutta ja hoidon laadun tasoa. Rintasyövän leikkausmenetelmä valikoituu syövän biologian sekä potilaaseen liittyvien tekijöiden mukaisesti (rinnan ja kasvaimen koko, terveydentila, toiveet). Tämä väitöskirja arvioi eri elämänlaatumittareiden käytettävyyttä rintasyöpäpotilaiden eri tautitiloissa sekä leikkaustekniikoiden vaikuttavuutta potilaiden elämänlaatuun. 840 rintasyöpäpotilasta rekrytoitiin poikkileikkaustutkimukseen vuosina 2009-2011 Helsingin ja Uudenmaan sairaanhoitopiirin (HUS)alueella. Potilaat vastasivat neljään eri elämänlaatukyselyyn: 15D, EORTC QLQ C-30, EQ5D-3L ja VAS. Potilaat jaettiin kyselyhetkellä vallitsevan tautitilan mukaan neljään eri ryhmään. 1065 uuteen rintasyöpään sairastunutta potilasta 2008-2015 rekrytoitiin seurantatutkimukseen HUS:n alueella. Potilaat täyttivät kaksi elämänlaatukyselykaavaketta: 15D ja EORTC QLQ-C30 BR23. Kyselyt toistettiin diagnoosihetkellä sekä postitse 3, 6, 12 ja 24 kk kuluttua diagnoosista. Potilaat jaettiin ryhmiin leikkausmenetelmän mukaan: rinnan osapoisto, rinnan kokopoisto, rinnan rekonstruktio. Hoitojen kustannustiedot haettiin tietokannoista. Potilaiden vastaukset yhdistettiin syövän hoitotietoihin ja arvioitiin tilastollisin menetelmin. Väitöstutkimus tuottaa uutta tietoa rintasyöpäpotilaiden elämänlaadusta eri tautitiloissa sekä valottaa miten rintasyöpäpotilaan elämänlaatu muuttuu syövän paranemisprosessin aikana. Eri elämänlaatumittareiden laajaa vertailu tuottaa uutta tietoa mittareiden vahvuuksista ja heikkouksista. Leikkausmenetelmien suhteen potilaiden elämänlaatu vaikuttaa olevan paras rinnan osapoistossa. Erityisesti rintaa muovaavia, ns. onkoplastisia tekniikoita käytettäessä potilaiden elämänlaatu ja kehonkuva on paras. Rinnan kokopoisto aiheuttaa eniten elämänlaatua huonontavia oireita. Rintarekonstruktiot tuottavat korkeaa elämänlaatua. Mahdollisuutta rekonstruktioon tuleekin tarjota kokopoistopotilaille. Rintarekonstruktiomenetelmien välillä ei havaittu merkitseviä eroja. Hoidon kustannusten ei tule olla määräävä tekijä valittaessa rintarekonstruktion ajankohtaa tai menetelmää, vaan toimenpiteet ja niiden ajankohta tulee räätälöidä potilaskohtaisesti. Kipu, väsymys ja uniongelmat ovat seikkoja, joihin tulee kiinnittää huomiota rintasyöpäpotilaiden hoidossa ja resurssien kohdentamisessa

Community-based exercise rehabilitation in a diverse chronic disease population

The effectiveness of physical activity (PA) for reducing the morbidity and mortality in individuals with chronic disease (CD) has been widely established. CD populations participate in lower levels of PA than their healthy counterparts. Currently research has focused on individual disease cohorts and limited evidence exists investigating levels of PA and SB in a mixed CD population. Study I used a cross-sectional study design to evaluate total daily PA and SB in men and women (62.98 ± 10.99 yr and 50.6% men) with a variety of CDs and examined the association between these behaviours and selected health indices. Participants spent 9.5 h.day-1, 4.1 h.day-1, 1.4 h.day-1, and 0.3 h.day-1 sedentary, standing, in light intensity PA (LIPA) and moderate to vigorous intensity PA (MVPA), respectively and on average took 6713 steps per day. The majority of SB was accumulated in bouts lasting ≥ 30 min. A higher daily step count was associated with more favourable measures of body composition, aerobic fitness and self-rated health. Increased daily sedentary time was associated with less favourable lower body strength. These findings highlighted that individuals with CD, regardless of specific condition, are a target cohort for intervention. Community-based exercise rehabilitation (CBER) programs have the potential to improve health outcomes in CD groups by increasing PA levels and reducing sedentary behaviour (SB). Historically such programs have involved single CDs. Given the similar programme design and the growing prevalence of multimorbidity (MM), an integrated model may be more suitable. MedEx Wellness is a novel CBER service in Ireland, which offers a shared programme to a range of CDs. In study II a quasi-experimental design was used to investigate the effects of a CBER program on levels of PA, SB and selected health indices, in men and women with a variety of CDs. There were significant improvements in LIPA, patterns of SB, physical function, body composition and psychological health following participation in a CBER program. A higher attendance to the CBER program was associated with improvements in measures of LIPA, MVPA, step count, time in sedentary bouts > 60 min, physical function, body composition and psychological health and psychosocial determinants of PA. These findings demonstrate that CBER is an effective approach to increasing PA and improving health related outcomes for individuals with CD, however statistically significant findings often mask the range of inter-individual variability that exists within response to CBER. In study III factors associated with an effective response to participation in a CBER, in terms of a measurable change, in men and women with a variety of CDs were explored. For measures of LIPA, strength, body composition and psychological health, a lower baseline (BL) value increased the likelihood of achieving a measurable change. A higher cardiorespiratory fitness (CRF) level at BL, increased the likelihood of achieving a measurable change. Individuals with cancer were more likely to improve measures lower body strength. Individuals with metabolic disease and respiratory disease were less likely to improve measures of LIPA and psychological health, respectively. Individuals with CD participate in low levels of PA and accumulate high levels of SB. A shared CBER program is an effective approach to inducing change in PA, SB, physical function and psychological health in a CD cohort. Identifying factors associated with a non-response to CBER could optimise program design and delivery

Exploring the physical activity behaviours, lived experiences and preferences of teenage and young adults with cancer and beyond.

Physical activity (PA) is beneficial for both physical and mental health, during and after cancer. However, there is a lack of research focusing on PA within the teenage and young adult (TYA) oncology population. This cohort have distinct physical and psychosocial needs, which may affect their PA behaviours. The aim of this thesis was to explore the PA behaviours, lived experiences and preferences of TYA's with and after cancer. This thesis comprises a scoping review of existing literature related to PA information, interventions, barriers and facilitators within the TYA oncology population aged 16-25 and an explanatory-sequential mixed methods study, utilising an online survey and semi-structured interviews. Overall, the qualitative findings confirm and explain the quantitative findings. Results demonstrate TYA cancer patients and survivors are insufficiently active and do not meet PA guidelines. Both the physical and psychological impact of cancer and its subsequent treatment were found to negatively affect PA behaviours within this cohort. TYA's were interested in PA and rehabilitation following treatment; however, they felt support offered from current services was too general and did not meet their individual needs. Findings highlighted a need for education regarding PA and cancer for both TYA's and their social networks, as well as an unmet need for instrumental and informational support from a healthcare professional (HCP) across the cancer care continuum. Instead of general advice, TYA's seek personalised support, tailored to themselves and their cancer, delivered via a 1-2-1 conversation. TYA's were also found to prefer in-person over virtual support but felt favourably towards a hybrid model. This population were found to self-source PA support through the internet primarily using Google, and the social-media platforms Instagram and YouTube. Although not an objective, this study also provides insight into the impact of COVID-19 on PA within the TYA oncology population. This research provides new knowledge and understanding about the PA behaviours, lived experiences and preferences of TYA cancer patients and survivors, emphasising the importance of personalisation and multidimensional social support. It highlights the need to evaluate the current PA support pathway within the Scottish TYA oncology services